I am a licensed NYC psychotherapist, hypnotherapist, EMDR therapist, and Somatic Experiencing therapist. My focus tends to be mind-body oriented psychotherapy. See my profile for more info. This site is not intended as a substitute for psychotherapy. No client-counselor relationship exists between the user and the owner of this site. To set up a consultation with me please call (212) 726-1006. All material on this site is copyrighted and cannot be used without permission.

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Monday, February 24, 2014

Psychotherapy: How Early Attachment Problems Can Affect Your Relationship With Your Therapist

In an earlier series of articles about early attachment bonds between infants and their primary caregivers, including How the Early Attachment Bond Affects Adult Relationships, I discussed how problems with early attachment can affect adult romantic relationships. In this article, I'll focus on how early childhood attachment problems can affect adults in their relationship with their psychotherapist.

How Early Attachment Problems Can Affect Adults' Relationships With Their Therapist

The attachment style that people develop early in life with their primary caregiver usually continues on in adult relationships.

When the emotional bond between the baby and the primary caregiver goes well, it's a secure attachment and if there's no major trauma in childhood, as an adult, this person will probably be able to form healthy, secure attachments in adult relationships.

How Attachment Problems Can Affect Adults in Therapy
When someone has an attachment problem that developed in early childhood, the insecure attachment doesn't just carry over only into romantic relationships. Depending upon the severity of the insecure attachment, it can also carry over into other adult relationships, including work relationships, friendships, and the therapeutic relationship with a therapist.

Generally speaking, people are complex, and people with insecure attachment styles don't fall into neat categories of avoidant, ambivalent, disorganized or reactive attachment.

But to illustrate the point that therapy clients often develop therapeutic relationships with their therapist based on their attachment style, I'll simplify the example I'm about to give in the vignette below to deal specifically with the avoidant attachment style. The same principles would apply for the other forms of insecure attachment, but they would probably show up in a different way.

As always, this vignette is a composite of many cases with all identifying information changed to protect confidentiality:

Ella
Ella, who was in her late 20s, came to therapy because she had a history of problems in her romantic relationships.

Although she was focused primarily on her problems in romantic relationships, Ella also had problems with her relationships at work. However, since she made a lot of money for the company, her superiors overlooked her interpersonal problems.

Ella said she wanted to meet someone that she could settle down with, get married and have children, but her relationships never lasted more than a year. She was also keenly aware that she would be entering into her 30s soon, and she was concerned about her "biological clock."

Her problem was that whenever a romantic relationship became serious, she became fearful that her partner would leave her.

In each relationship, Ella's fear became a self fulfilling prophecy because, even though she loved the man she was in a relationship with, her fear would become so overwhelming that she would become avoidant and start to distance herself from him.

She did this by finding all kinds of reasons for canceling plans, making excuses, including that she didn't feel well or that she had too much work to do.

Sooner or later, the man she was seeing at the time would get fed up and leave the relationship, and Ella would feel sad and frustrated.

After this happened in three relationships, Ella also began to feel angry with herself because she couldn't understand why she was sabotaging each relationship. It also left her feeling very lonely.

Each time this happened, Ella would promise herself that she wouldn't give in to her fears in the next relationship. But each time her fear overwhelmed her in the next relationship, and she found ways to distance herself again.

Knowing that clients' attachment styles can affect their therapeutic relationship with their therapists, I usually address this issue early on in therapy to educate clients so they won't be surprised to see that they're engaging in the same dynamic in therapy.

When a client with this problem knows in advance that it can affect how they engage (or disengage) in therapy, it can help clients to anticipate this before it happens. It gives the therapist and client an opportunity to talk about it before client acts on it.

Although talking about it beforehand can help to mitigate an insecure attachment style, simply having this information doesn't necessarily stop it.

Attachment dynamics are usually unconscious, so that when a client engages in an insecure attachment style in therapy, s/he isn't necessarily aware of it at the point when it's happening.

It can take a while for a client to develop enough awareness in therapy to anticipate the behavior and, even more time to change it.

Ella was psychologically minded, so she was surprised and curious about how this avoidant dynamic might play out in therapy.

In the initial stage of therapy, as I was learning about Ella's family history and how it contributed to her insecure attachment style, Ella seemed fine. She had been in therapy several times before, and she had talked about her family history many times before. She was almost somewhat detached and unemotional as she gave her history.

When Ella told me about the many false starts she had in her prior therapies, I pointed out to Ella that, just like she found ways to be avoidant in her romantic relationships, she also became avoidant in her therapeutic relationships with prior therapists.

Ella's Avoidance in Prior Treatment Was Unconscious

Ella had never thought of this before but, as we discussed it, she realized that she usually left therapy just when she and the therapist were at the point where they were delving deeply into her problems. Whenever she left therapy, she thought she was doing it because "it wasn't helping."

But, as we discussed this, Ella was able to see, in hindsight, that she didn't really give any of her prior treatments a chance because she would leave before she made progress.

We spent time talking about the internal cues that Ella might have missed before she aborted therapy in the past, and we also talked about whether she could pick up on these cues this time if she felt like aborting therapy again.

For many clients, this is hard work, especially for clients who really believe that, each time they leave therapy, it isn't because they're avoiding dealing with their problems. They want to believe that they have a legitimate reason each time because "therapy isn't working."

This isn't to say that clients don't leave therapy for legitimate reasons or that their therapist really isn't helping them. But for clients who have an avoidant attachment style, they often have a pattern of leaving therapy prematurely (see my article: When Clients Leave Psychotherapy Prematurely).

In addition to discussing Ella's avoidant behavior in therapy, as part of our preparation for our work, we also worked on helping her to develop coping strategies to deal with her anxiety and fears.

We also talked her commitment to therapy and the treatment frame, including my cancellation policy, which is 48 hours unless there's an emergency.

Although this preparation helped Ella to deal with her urges to leave therapy during the early stage of treatment, as we delved deeper into Ella's early childhood history with an unstable mother, Ella began to cancel appointments more frequently.

For many people, a cancellation policy where they had to pay the full fee for broken appointments can be a deterrent to their canceling appointments when they want to cancel because they're uncomfortable with the material that we were discussing in the prior session.

But Ella earned a very good salary and it wasn't a hardship for her to pay for broken appointments. So, the cancellation policy didn't keep her from missing sessions. She also became adept at canceling the appointments 48 hours in advance so, technically, she complied with the cancellation policy but, in effect, she was sabotaging her treatment because of her fears of dealing with emotional material that came up.

At the point when she cancelled the appointments, she had no insight as to what was happening with her because her fears were unconscious at the time. It was only after she returned to her therapy sessions and we discussed what happened that she was able to see, after the fact, that she was being avoidant.

Fortunately, even though there was a part of Ella that was ambivalent about dealing with her problems in therapy, there was a bigger part that was motivated. So, we worked with the motivated aspect of her in therapy to strengthen it so she wouldn't allow the fearful part of herself to sabotage her sessions.

We also had to develop some new ground rules that we would mutually agree to about cancelled appointments. So, we agreed that she could only have so many cancellations per six months, and she was able to abide by that.

Since regular talk therapy often isn't as effective for insecure attachment problems, we used a combination of Somatic Experiencing and clinical hypnosis, which are both mind-body oriented therapies that are considered a "bottom up" approach as compared to regular talk therapy, which is more of a "top down" approach.

Ella's therapy was long-term treatment because, even though she was making progress over time, she would sometimes revert to avoidant behavior. So, our work together required patience on both of our parts. But as we continued to work together, Ella began to trust me more over time and this allowed her to open up more.

And, as is usually the case, the interesting thing was that as she was developed the skills to form a stronger, stable therapeutic alliance with me, she used these same skills to form a more stable relationship with the new man that she was dating as well as her colleagues at work.

Over Time, Ella Worked Through Her Avoidance in Therapy and in Relationships

Over time, Ella worked through her avoidant behavior, and when she felt the urge to withdraw out of fear, she was able to see the signs before she acted on it, which was a major breakthrough for Ella.

The Challenge of Working on Insecure Attachment in Therapy
Working on any one of the insecure attachment styles in therapy can be challenging for the client and the therapist.

In the vignette that I presented above, even though Ella was fearful, she also had strengths and she had access to a part of herself that was motivated to overcome her avoidant behavior. She was able to use the therapy well and, over time, she was able to work through her early childhood trauma and overcome her fears.

Many people who have an avoidant attachment style never come to therapy at all. Their fear of developing a therapeutic relationship with a therapist is so great that, unfortunately, it keeps them out of therapy and, as a result, they never work out their problems in relationships.

For other people who start therapy and who might not be as motivated or as psychologically mind, they often have a hard time sustaining it. They might go from one therapist to the next in an effort to get help, but they don't remain in therapy long enough to work through their problems. Sometimes, in hindsight, some of these clients see that their fear overwhelmed them.

But other people with this problem, no matter how many different therapists they see, they tend to externalize their problems and believe that they left because of the therapist as opposed to what usually happens: They leave because of their insecure attachment style and the fear and dread that are associated with this problem.

When you consider that overcoming an insecure attachment style is not short term work, this presents another challenge for these clients.

Getting Help
The good news is that many clients who come to therapy to overcome the consequences of problems with early attachment are able to work through these problems.

Just like in any other therapy, it's important for the therapist and client to be a good match.

It's also important that the therapist, who should be a licensed mental health professional, is knowledgeable about insecure attachment issues.

Also, in many cases, as I mentioned earlier, straight talk therapy, which is usually a "top down" approach, isn't as effective as a more "bottom up" approach in therapy, like Somatic Experiencing, EMDR or clinical hypnosis.

If the composite vignette above resonates with you, you could benefit from working with a licensed therapist who has expertise in working with clients who have attachment problems.

It's common for most people to feel some discomfort about starting therapy. But it's preferable to deal with the fear than to look back late in life and have regrets that life has passed you as you continue to suffer with attachment problems.